Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Sunday, October 23, 2005

Asthma mystery

From Doug:

This is not so much a diagnostic dilemma, as a therapeutic curiosity. Think of it as a riddle. This is a very nice lady whom I cared for about 5 years before she was lost to follow up because of an insurance change. She initially came to my clinic after being followed by another colleague who left the University after finishing training. This lady had very severe asthma, with persistent symptoms, and frequent exacerbations that required steroid burst & tapers. She was also quite obese and as a result had some restrictive physiology that was not accompanied by any evidence for interstitial disease on full PFTs and HRCT scans done on multiple occasions throughout the years. After a while I ran completely out of options for her. She was compliant on 6 puffs of Flovent bid, Serevent, Accolate (this was before Singulair), et., and was still ending up in an emergency room every 4-6 weeks.

I started her on a drug that we shall henceforth refer to as "Mystery Drug". I had a biologic rationale for it, but NO DATA whatsoever, other than I knew it to be acceptably safe. I will see if anyone can guess what I started her an and why, then post some follow up.

10
comments - CLICK HERE to read & add your own!:

Doug, we've discussed this case before, so I won't give away the "mystery drug." I do think that this case revisits one that we've discussed before one this blog regarding "refractory" or "difficult to control" asthma. (See the case titled "Reactive Airway Disease? http://pulmonaryroundtable.blogspot.com/2005_06_01_pulmonaryroundtable_archive.html)

So, for the sake of discussion (without going into treatments), how were "non-asthma" mimics and other "causes" of treatment failure evaluated- (i.e. laryngeal dyskinesia, psychogenic dyspnea, non-compliance with standard therapy, CS, ABPA, CHF, mitral stenosis, to name a few)?

Jeff, I should have mentioned that the "Z" was a trial of Zileuton. As far as asthma mimics, she had multiple HRCTs and also a thorough cardiac evaluation. She was diagnosed with "CHF" but also had an EF of 55%. She had vocal coed revaluations by everyone from our guy to several in the Flint area.

She had clear reactive airway disease as evidence by reversible, severe, obstructive disease with documented respose to steroids and bronchodilators as well.

One of the reasons I posted this was that she came back to see me last week, after three-and-a-half years, still on drug "x" and still has not been on any steroids by her report since I saw her.

Are there any clues in the history you provided to indicate *which* steroid-sparing drug she was on? If not, it could be any none-standard but anti-inflammatory med:Methotrexate (but I don't think the effect is very large, if I remember correctly); Azathioprine would be a good guess since you said you chose something with no data to support it; Chloroquine (very spotty data to support this); macrolide (because of the anti-inflamm component or perhaps because of MAC according to the researcher in Denver - what was his name?); I'll avoid things like an oral leukotriene receptor antagonis since that has data behind it;

You didn't mention anything on IgE levels but I will add Xolair to Jennings' list. I like Jennings' suggestion of a macrolide since there is biological data for other airway conditions but it is not as solid data in asthma.GERD treatment could improve asthma control as well but then you wouldn't be talking about the biological rationale...Was she post-menopausal? There are small series on asthma control worsening in post-menopausal women...

I'm guessing it's not Xolair since she was lost to f/u and that's initially requires monthly - bimonthly injections in the clinic - although patient can be instructed to self inject after dose tolerance and effects have been observed.

A'ight, Ill move on here. This was about 7 yrars ago so Xolair was not even a wink in my daddy'e eye at that time. I had been working in the lab with doxyxycline as an angiostatic agent in some in vitro experiments and there was a paper that had come out in 1997 on minocycline in rheumatoid arthritis.

My rational was that the severity of this lady's asthma implied significant airway "remodeling" (whatever you belive that to be...I believed it to be a process that required angiogenesis, and I figured what the hell).

I started her on doxy 100 mg b.i.d. and her PFTs shot trough the roof. In six months she was completely off prednisone, and only once had trouble when she stopped it after being hospitalized at Hurley where a well meaning intern told her to stop the drug "...if you can't tell me why you're taking it". PUtting her back on doxy fixed her "relapse" and she has been on it since.

She came back to U of M recently for another reason, and is still doing well three-and-a-half years since I last saw her.

Here at, Disease.com, we have worked with elite organizations who strive to find a cure for diseases and infections. After reading through your website, it is clear your organization shares the same passion we do for spreading the awareness for Asthma. Disease.com is a website dedicated to the preventions and treatments of diseases, as well as an established, medical news outlet. If you could, please list us as a resource or host our social book mark button, it would be much appreciated. You fight the cause, we'll spread the awareness.If you need more information please email me with the subject line as your URL.